TRICARE Supplement Plan for Active Employees

The TRICARE Supplement Plan is administered by Selman & Company and underwritten by Transamerica Premium Life Insurance Company and Transamerica Financial Life Insurance Company for New York residents only.

TRICARE-eligible employees who are also eligible for the State Health Benefits Program and are in one of the following categories may voluntarily enroll in the supplement plan:

Military retirees who are entitled to retiree, retainer or equivalent pay and their spouses/surviving spouses who are not eligible for Medicare.

Retired Reservists and National Guardsmen between the ages of 60 and 65 with 20 years of creditable service and their spouses/surviving spouses who are not eligible for Medicare.

Retired Reservists and National Guardsmen under age 60 and enrolled in TRICARE Retired Reserves (TRR) and their spouses/surviving spouses who are not eligible for Medicare.

Military retirees and their spouses/surviving spouses who reside outside the U.S. or its territories (all who are eligible for Medicare must be enrolled in Medicare).

Military retirees and their spouses/surviving spouses age 65 or older but ineligible for Medicare (all must have received a Statement of Disallowance from Social Security Administration).

Available to Qualified national Guard and Reserve members (TRICARE Reserve Select)

Advantages of the TRICARE Supplement Plan:

Available to all TRICARE participants regardless of rank or service

No medical examination required for enrollment

No pre-existing condition clause

No supplement plan deductibles

Covers the TRICARE Standard deductible at 100% and the TRICARE POS deductible at 50%

Covers 100% of copays

Covers all excess charges (to the legal limit)

Flexibility and freedom to see any TRICARE-authorized civilian providers

Full portability if your enrollment with the Commonwealth of Virginia ends

Guaranteed Issue

The TRICARE Supplement Plan works with all three TRICARE options (Standard/Extra, Prime and TRICARE Reserve Select) to pay the following benefits.

Under the TRICARE Prime or Point of Service (POS) option, the supplement plan pays:

100% of the TRICARE Prime copayments or cost shares

50% of the POS deductible of $300 individual (maximum $600 family)

100% TRICARE Prime POS cost share

100% applicable Excess Charges (up to the legal limit)

Under the TRICARE Reserve Select option, the supplement plan pays:

100% of the TRICARE Reserve Select Outpatient Deductible of $150 per person (maximum $300 per family)

100% of the TRICARE Reserve Select cost share

100% of applicable Excess Charges (up to the legal limit)

*MONTHLY PREMIUM SCHEDULE

Employee Only

$61

Employee plus One

$120

Employee plus Two/More

$161

*Washington State Residents have a different Washington
State mandated premium amount.

The TRICARE Supplement Plan communication links provide more detailed information on the coverage and benefits provided.

MAKING PREMIUM PAYMENTS: Monthly premiums will be payroll deducted on a pre-tax basis.

MORE INFORMATION: Call Selman & Company’s toll free number at 1-800-638-2610, option 1 for questions about Open Enrollment or other questions about the TRICARE supplement. You may also visit the website at www.selmantricareresource.com/cova.